S 3060 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO,
BUILDING DIVISION APPLICATION/1'ERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENT'IF'ICATION .3060
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1x337 1- 1,v'b# Jls�g boo
OWNJ44bTTOd 1AIaCI^:xIUf55 AMLLV
_Tnr / N❑/C
CONTROL#
ARCHITECT/ENGINEER: LIC NODRE�SN
Ile
3b'L S A-eA-t{v a
CONIAC'E PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMS MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby a1Rrm that 1 am licensed under powilime abchapmr 9(commencing JOB DESCRIPTION
F�O t>;Z with Section9000)rf Drviould 3,dlw Buvnessand Profesatone Cade.andmy lereasels RESIDENTIAL'
� full furca and effect II PERMIT ISSUANCE
=WPa4UU License Class C-�L Lia# ff 15 ❑SFUWL C1 KITCHEN REMODEL
-RGSIUENTIAL
P
Dam C.."ador [:]ADDITION ❑PLUMBING RE-PIPE
A CHITECI"S DECL T'l0 PANELS ❑ I-U
MULTNIT []STRUCTURAL
F-
OmZ lundersiand my plans shall be used as publ¢remrds MODIFICATION
Z 4.. UP TO 200 AMPS
F.4,, W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
201-1)10 AMPS IMPROVEMENT
C:C„_1 OWNER-BUILDER DECLARATION
L]SWIMMING POOLS
C ¢ I hereby air,,.that 1 am exempt from the Contractor,Liver,,Law far the OVER 1000 AMPS El BATH RP,MODR_WI2ERAIR DEMOLITION
00'3 U fallowing reason.(Section 90315,Bust....and Profession,Cade:Any city or county SIGNS ELECTRICAL ❑OTHER S �r.F• I�QI trN VUt
y which requires a permit to dmsmuct alter.Improve,demolish,lir repair any structure F A e P A
„F]��Q priormitsinuencq also rWueres the applicam for smM1 permnwfileasignW emwin no
SPECIALCIRCUIT/MISC.
'y'•' that he is licensed pursuant to the provisions of fie Contractors License Law(Chapter 9 �R x'iste �0� 0
(cammenc5ng with Section 9(NEpnf Division 3 afthe Businessand Professions Cade)or TEMP.METER OR POLE INSI.. COMMERCIAL
d m
IES he Is exempt therefrom and the basis for the alleged exemption.Any violation of EJ NEW BLDG/ADDITION ElDEMOLITION
n: Section 9031,5 by any applicant for a pennit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT
ern ❑FOODSERVICE
not mom than five hundred dollars(5500). IMPROVEMENT
.F+E I,as own.of ihepropeny.ornry employees with wages as melt aolecompe...ran, SWIMMING POOL ELECTRIC
F. will do the work,and the structure is not intended northeast Fascia(Ser.9044,Business EJ OTHER
WM 3 se Sad Professions Code.The Contmdo's License Law does not apply to an owner of DO['LE'I S-SWITCHES-FIXT R�
.. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended of offered bar NEW RESIDENTIAL L'LECTR S
sale.If,however.the budding lir improvement I%sold within one year efcompletiom,the SQ.FT.FLOOR AREA $/SQ.PP.
der-builder,will have the buNen of proving that he did ort build m Improve far par-
RoseofsaleJ.
❑I,as owner of the pmpeny,am exclusively comment,with licensed usnPamnm tr TOTAL.
answer thein fort(Ser,7041,Business and Professions Culex)The Cammcmrs LI-
nseLaw does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contract%for such projects with a conmacmrfs)licensed pursuant to the Connector's
License Law. ' PERMIT ISSUANCE
1 um exempt under Sec. ,B&P C for this reason TI
Owner Irate ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby aBrm under penalty o[penury one of the following declarationsLj :
I have and will maintain a Certificate rt Consend"elf-insure for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,COND.
salon,as provided for by Section 3]00of the Labor Code,for the perfmmancc of the 9'I'ORIES TYPE CONSTRUCTION
work tar which this Perini(is issued. FIXTURES-PCR TRAP
❑ 1 have and will maintain Workers Compensation Insurance,os required by Section
3700afthe Ldour Cede,Farther performance ofthe work for which this permit is issued GAS-EA.9Y9TRM-I INC.40UTLBTS OCC.GROUP APN
My Workers rypensationlnssyya %artier and Policy
number u(e:
Cartier: C'a W._ 4,At L( ct Policy No.: IuvC iSL11AY d� GAS-EA.SYSTEM-OVER4(EA) _
CERFIFICAT O— FrEXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE GREASE NDUSTRL WASTE INTERCEPTOR
(Thee Section need not he completed if the permit is for one hundred dollars(A 100) BUILDING DIVISION FEES
or leas) su PLANCHECK FEP,
Ia,mythat,domthe perfonnenaofinew s all
non employ any person in any manner so esu be come subjec ml Workers' npem SEWER-SANT"1'ARY-STORM EA.201)Ff. ENERGY FEE
,7., stolon Lawsnf Califon.Da le L�
z O Applicant t WATER HEATER WNENT/ELE.CIR GRADING FEE
Ir N NOTICE TO APPLICANT:If,atter making t nificme of Exemption,you sho Id WATER SYSTENV REATING
(~ becnme Subjecuo the Waders Comp irmio �yry�lt{�� ryrA�n --^{al��t SOILS PEE
Lai� Q forthwith comply with.such Ovenans orchis rvnssh�1111e ,.2m ,MkeJ"__ WATER SERVICE 11
CONSTRUCTION LE r NG AGENCY
UC) NEW RESIDENTIALPLMB. SQ.FT PAID
V l for
inuha Iiward(See nlending agency for me performance of Date Receipt#
Fthe work for which phis permit is issued(Sec., 19B e CJ
U Lenders Name D TOTAL:
W Lente I Address OTA1.
I certify that I have read thisapplicationand
and arum that the shove information is BUILDING FEB
rap cored.lagree mnemply with e,0 city and rs,amyntatives of and atomlmwsrupon tit,he QTY. MECHANICAL PERMIT FEE
C.) ,Zi .basengcdmciradton.end hereby ectim. ercprescnmtivexrhhls city to enter upon me SEISMIC EEE
ahnve-IWS)agrepto ertySave fnremnifyian rr,keep
PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEB
liabilities.judgments,costs and expenses which may in any way acme against Said City ALT ER OR ADD TO MECH.
in nasequedce of me grating of OLs permit. PLUMBING FEE
APPLICANT NT UNDERSTANDS AND WILL COMPLY WITH ALL NDN-POINT AIR HANDLING UNIT(TO I11,N)O CPM)
SOURCE REGULATIOSN,Sf. MECHANICAL FEB
(N_ 0 ,r, CJkyt�+ I ohi,�J t/ AIR HANDLING UNIT(OVER IO.INIO CPM) CONSTRUCTION TAX
ldaPtn'r"e'ofApppplicanUCrntxacmrll//" WW^^ [hie / EXHAUST HOOD(WNUC'O HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building oreapantstore or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupema,Municipal Cade,Chapter 9.12,and the Health and Surety
Code,Section 25532(.)? HEATING UNIT(OVER 1OD,g10 If
❑Yes ❑No
VENTILATION PAN(SINGLE R2SID) PAID D
e Will me a lieant or a M1 defined
u i use e t or devices which Dnic Receipt#
pp gxc pan quipmw BOILER-COMPf3HP OR 100.000 UTU)
coir harardnw as contaminants as defined by the Bay Arca Air Quality Management OTAL.
DisWct?
El Yes ❑Nm BOILER-COMP(OVER I0N1,00 BTU)
I have read tire hazardous materials requirements under Chapter of the Cali- AIR CONDI'T'IONER
9 p ISSUANCE TE
fomlu Realm&Safety Gide,eatenas 25505.25533 and 25534.1 understand i(ir ff me NEW RESIDENTIAL.MECH. SQ.P.
building does not currently have a mon prior
isua responsibility of aCrmroilymepancy.m
of the rWuiremenis which must he met prior m issuance of n Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY'. T �/
OFFICE